Could This Be the End of Health Care Reform?

SAUSALITO, CA (ASRN.ORG) -- What if the Supreme Court declares unconstitutional the Affordable Care Act’s requirement that everyone buy health insurance? What if it strikes down all the act’s insurance provisions, including the requirement that insurance companies cover everyone, regardless of pre-existing illnesses? Would this totally put an end to the health care reforms we have passed in the last three years?

Absolutely not.

The essence of the case the Supreme Court will begin hearing on Monday is whether, invoking its powers in the commerce clause of the Constitution, Congress can require individuals to purchase health insurance or pay a penalty. I believe the mandate is constitutional, but no matter how the court rules, many health care reforms that were approved by Congress through the Affordable Care Act and other recent bills — like those to promote electronic health records, encourage coordinated care, reduce medical errors and cut costs — will proceed.

No matter how the court rules, many health care reforms will proceed.

Tens of thousands of Americans die because of hospital-acquired infections every year, and far more are harmed by medical errors. Last year, authorized by the Affordable Care Act, the Obama administration announced a $500 million program called Partnership for Patients aimed at reducing hospital-acquired infections, errors and other preventable complications. The act also requires Medicare to begin posting online each hospital’s rate of certain medical errors and infections, and to cut payments to hospitals with the highest rates.

Consequently, hospitals across the country are working to reduce preventable hospital errors. Once it’s clear that this is a major priority, significant progress can be made. A few years before the health care reform act was passed, the Hospital of the University of Pennsylvania, where I work, started paying attention to reducing preventable errors, and it managed to reduce infections from intravenous lines to 1 or fewer per month from 30 to 40 per month. All it took was removing intravenous lines whenever they weren’t necessary, changing them regularly and using a more vigorous sterilizing technique when inserting them. Many other institutions are making similar progress now. All of this has nothing to do with the constitutionality of the individual mandate and will continue no matter what the Supreme Court rules.

The same goes for the problem of hospital readmissions. Right now, nearly 20 percent of Medicare patients who are discharged from a hospital are readmitted within 30 days. Some are scheduled readmissions; others occur for completely unrelated health problems, like falls and accidents. But many could be prevented by paying more attention to the coordination of care between physicians and hospitals and by better follow-up after patients are discharged. Beginning this year, the health care reform act will penalize hospitals that have high readmission rates for three conditions: pneumonia, heart failure and heart attacks. This list will later be expanded. As a result, all hospitals are now scrambling to figure out how to create “the perfect patient discharge” so patients don’t become hospital “frequent fliers.”

Other progress is being made that will not be affected by a court ruling on the mandate. Thanks to the act, there has been a growth of accountable care organizations — groups of physicians and hospitals that come together to deliver coordinated care at a lower cost and to share in potential savings. Many health policy experts think these organizations are our best hope to improve care and lower costs.

The act also lays the groundwork for a more efficient payment system. Today, payment for a knee replacement, for example, is à la carte: fees for the orthopedic surgeon, the anesthesiologist, the radiologist, the hospital and operating room and the physical therapist are all paid separately. Under the health care reform act, Medicare is instructed to conduct 10 pilot programs with “bundled payments,” in which there is one fixed price for the whole episode of care. Preliminary data suggest that bundled payments can produce significant efficiencies and cost savings, and improved quality through better coordination of care.

And a few reforms that have nothing to do with the Affordable Care Act will continue as well. The American Recovery and Reinvestment Act — the 2009 stimulus — contained provisions to promote the expansion of electronic health records, which allow physicians to more closely track patients, especially the chronically ill, and enable the seamless exchange of data among multiple physicians, hospitals and other providers. In just the few years since, there has been tremendous progress: before, just 16 percent of hospitals had electronic health records; now 35 percent have them. Before, 17 percent of doctors used electronic records in their offices; now 34 percent do.

Of course, one big thing will change if the court rules the individual mandate unconstitutional: Instead of the 32 million Americans predicted to gain coverage under the health insurance reform act, only around 16 million Americans would gain coverage. Even with subsidies for buying insurance, some healthy people would opt out of the state health insurance exchanges authorized by the act. This would drive up premiums by an estimated 15 to 20 percent and push more healthy people out of the market, creating a downward spiral until the only people buying insurance are those who are very sick. While many states may still try to move forward with their exchanges without the mandate, they will eventually collapse.

If the Supreme Court rules that the individual mandate is unconstitutional — in my opinion, an improbable and legally indefensible decision — it will not end health care reform. Hospitals and doctors will continue to work to improve care and control costs. But tens of millions of Americans will continue to be excluded from the health care system, which is hardly an optimal outcome.

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